Release of Medical Information

Please correct the errors described below.

Please provide the information of whom we are requesting from or releasing to:

I hereby authorize the release of the above-mentioned medical records and will not hold the releasing party responsible for any legal liability that may arise as a result of the release of this information.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of parent or authorizing party:

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